Thyroid storm triggered by thyroid nodule fine needle aspiration biopsy: a case report

Thyroid storm is a potentially fatal thyrotoxicosis triggered by an event, such as manipulation of the thyroid gland, acute iodine load, trauma, or infection. Prior to deciding on fine needle aspiration (FNA) biopsy, patients who have been diagnosed with hyperthyroidism or low thyroid stimulating hormone and multinodular goiter (MNG) should be imaged via radionuclide thyroid scan.

We present a case of a 62-year-old female patient with history of MNG, who had thyrotoxicosis on presentation due to medication noncompliance and was found to have Graves' disease. Computed tomography scan without intravenous iodine contrast injection showed a heterogeneously appearing and notably enlarged thyroid gland with a 6.2 cm × 5.8 cm right thyroid lobe and 5.5 cm × 5.0 cm left lobe. There was a resultant narrowing of the trachea measuring 6 mm in the transverse dimension at its narrowest point. Further evaluation with dedicated ultrasound of the thyroid showing bilateral MNG with coarse calcifications as well as a notable left thyroid cyst measuring 1.6 cm × 1.2 cm × 2.3 cm, isoechoic, with smooth margins. The patient was started on methimazole 40 mg/day, cholestyramine 4 mg four times per day, prednisone 20 mg/day, saturated solution of potassium iodide 50 mg three times daily, and propranolol for heart rate control. Another service recommended FNA biopsy of the right 3 cm thyroid nodule. Two days after undergoing an FNA, she experienced a thyroid storm, requiring emergent total thyroidectomy as a life-saving procedure.

FNA is rarely needed in the case of a hyperfunctioning thyroid nodule, as it can be seen on radionuclide thyroid scan. However, when executed, a euthyroid state needs to be achieved before attempting to perform an FNA. Total thyroidectomy is warranted in a hyperthyroid state in an emergent setting without ample time for medical therapy to be effective, as seen in our reported case.